HIM 1423 All Tests Questions and Answers Fully Solved Latest Version 2025-2026
The _______ is responsible for development and maintenance of RxNorm - Answers The NLM
develops and maintains RxNorm.
The ___________ is responsible for the publishing and maintaining HCPCS Level II. - Answers
CMS publishes and maintains HCPCS Level II
Which of the following is the standard for clinical lab test results under the Meaningful Use
program? - Answers LOINC is the standard for clinical lab test results as per the Meaningful Use
program.
The standardized HEDIS data elements are collected by _________. - Answers Clinics and
hospitals collect the standardized HEDIS data elements from health records
The ________ originated from federal reporting requirements tied to certification criteria found in
the Meaningful Use regulations. - Answers The Office of the National Coordinator for Health
Information Technology (ONC) established a common set of data types and elements and
associated standards for use across several certification criteria. The combination of these
items is called the Common Clinical Data Set.
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders? -
Answers The APA developed the DSM to be the standard medical classification for mental
disorders.
ICD-10-PCS is a classification of _________. - Answers The purpose of ICD-10-PCS is to provide a
system for classifying procedures performed on hospital inpatients.
The SNOMED CT _________ includes the semantic tag. - Answers The fully specified name is the
unique text assigned to a concept that completely defines it. The term enclosed in parentheses
at the end of the fully specified name is called the semantic tag.
Home health agency process and improvement outcome measures are based on data from the
_____. - Answers The CMS Home Health Compare website's information on home health agency
process and improvement outcome measures are based on OASIS data submitted by home
health agencies to state repositories.
The UHDDS's core data elements were incorporated into the ___________ prospective payment
system - Answers When diagnosis-related groups were implemented, UHDDS definitions were
incorporated into the inpatient prospective payment system regulations
A ___________ is a set of terms representing the system of concepts for the medical field. -
Answers This is the definition of a clinical terminology.
Category I CPT includes which of the following? - Answers Category I CPT includes six main
sections one of which is Surgery.
,One of the two major groups of LOINC content is _________. - Answers There are two major
groups of LOINC content—laboratory and clinical.
The ___________ is responsible for the development and maintenance of ICD-10-CM. - Answers
The governmental body responsible for developing and maintaining ICD-10-CM is NCHS.
If you were looking for a code for a medication taken orally, in which system is it found? -
Answers RxNorm is a standardized nomenclature for clinical drugs.
A classification provides clinical data to ______________. - Answers Classifications aggregate
clinical data for healthcare statistics.
WHO defines ___________ as a reference classification. - Answers ICF is one of the three
reference classifications approved by WHO-FIC.
An accumulation of numeric or alphanumeric representations or codes for exchanging or
storing information is a ___________. - Answers This is a definition of a code system
LOINC would be found in the UMLS ____________. - Answers Code systems are found in the
UMLS Metathesaurus. LOINC is a code system.
The _________ is a system for classifying the topography and morphology of neoplasm. -
Answers ICD-O-3 is the system used by tumor or cancer registries for classifying the
topography and morphology of neoplasms.
The ___________ is a core component of SNOMED CT. - Answers SNOMED CT is made up of
three main components—concepts, descriptions, and relationships.
If data aggregation is the goal of collecting the data, ______ are the best choice. - Answers A
classification combines related entities. Aggregate data is appropriate when the combination of
data about related entities is sufficient.
___________ is a nursing terminology. - Answers The Clinical Care Classification is a nursing
terminology. The others are classifications.
HCPCS is made up of which code systems? - Answers HCPCS is made up of two code systems:
Level I and Level II. Level I is CPT.
Which standard is attached to the data element smoking status contained in the Common
Clinical Data Set? - Answers The data element smoking status must be reported with SNOMED
CT identifiers.
Which organization originally published ICD-10? - Answers WHO - World Health Organization
Which of the following provides the most comprehensive, controlled vocabulary for coding the
content of a patient record? - Answers SNOMED CT
, Who drives which clinical terminology, classification, and code system is selected as the
standard? - Answers Government regulation
The OASIS-C1 data elements originate from a _________. - Answers Medicare-certified home
health agency
Which of the following terms refers to the incidence of disease? - Answers Morbidity
To gather statistics for surgical services provided on an outpatient basis, which of the following
codes are needed? - Answers CPT codes
Which of the following is the condition established after study to be the reason for
hospitalization? - Answers Principal diagnosis
Which coding system has a section for Evaluation and Management services? - Answers CPT
If you were coding a patient with the diagnosis of congestive heart failure, which classification
would you use? - Answers ICD-10-CM
Which of the following classifications is used exclusively for classifying cases of malignant
disease? - Answers ICD-O-3
The first character for all of the codes assigned in ICD-10-CM is - Answers an alphabet.
The Level II (national) codes of the HCPCS coding system are maintained by the - Answers
Centers for Medicare and Medicaid Services
Which of the following is used to report the healthcare supplies, products, and services provided
to patients by healthcare professionals? - Answers HCPCS
Name two roadblocks to high quality coding. - Answers Coders who do not get correct or
updated training, and physicians who do not complete their charting on time
A list of recommended data elements with uniform definitions is a _______. - Answers Data set
The Uniform Hospital Discharge Data Set's core data elements are collected by ______. -
Answers Acute care, short-term stay hospitals
I need to confirm the patient's principal diagnosis for the chart I am coding. How should I do this?
- Answers Review documents such as nursing notes and laboratory reports
Which of the following is a standard terminology used to code medical procedures and services
and is maintained by AMA? - Answers CPT
The Unified Medical Language System (UMLS) is a project sponsored by the - Answers National
Library of Medicine.
CMS.
The _______ is responsible for development and maintenance of RxNorm - Answers The NLM
develops and maintains RxNorm.
The ___________ is responsible for the publishing and maintaining HCPCS Level II. - Answers
CMS publishes and maintains HCPCS Level II
Which of the following is the standard for clinical lab test results under the Meaningful Use
program? - Answers LOINC is the standard for clinical lab test results as per the Meaningful Use
program.
The standardized HEDIS data elements are collected by _________. - Answers Clinics and
hospitals collect the standardized HEDIS data elements from health records
The ________ originated from federal reporting requirements tied to certification criteria found in
the Meaningful Use regulations. - Answers The Office of the National Coordinator for Health
Information Technology (ONC) established a common set of data types and elements and
associated standards for use across several certification criteria. The combination of these
items is called the Common Clinical Data Set.
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders? -
Answers The APA developed the DSM to be the standard medical classification for mental
disorders.
ICD-10-PCS is a classification of _________. - Answers The purpose of ICD-10-PCS is to provide a
system for classifying procedures performed on hospital inpatients.
The SNOMED CT _________ includes the semantic tag. - Answers The fully specified name is the
unique text assigned to a concept that completely defines it. The term enclosed in parentheses
at the end of the fully specified name is called the semantic tag.
Home health agency process and improvement outcome measures are based on data from the
_____. - Answers The CMS Home Health Compare website's information on home health agency
process and improvement outcome measures are based on OASIS data submitted by home
health agencies to state repositories.
The UHDDS's core data elements were incorporated into the ___________ prospective payment
system - Answers When diagnosis-related groups were implemented, UHDDS definitions were
incorporated into the inpatient prospective payment system regulations
A ___________ is a set of terms representing the system of concepts for the medical field. -
Answers This is the definition of a clinical terminology.
Category I CPT includes which of the following? - Answers Category I CPT includes six main
sections one of which is Surgery.
,One of the two major groups of LOINC content is _________. - Answers There are two major
groups of LOINC content—laboratory and clinical.
The ___________ is responsible for the development and maintenance of ICD-10-CM. - Answers
The governmental body responsible for developing and maintaining ICD-10-CM is NCHS.
If you were looking for a code for a medication taken orally, in which system is it found? -
Answers RxNorm is a standardized nomenclature for clinical drugs.
A classification provides clinical data to ______________. - Answers Classifications aggregate
clinical data for healthcare statistics.
WHO defines ___________ as a reference classification. - Answers ICF is one of the three
reference classifications approved by WHO-FIC.
An accumulation of numeric or alphanumeric representations or codes for exchanging or
storing information is a ___________. - Answers This is a definition of a code system
LOINC would be found in the UMLS ____________. - Answers Code systems are found in the
UMLS Metathesaurus. LOINC is a code system.
The _________ is a system for classifying the topography and morphology of neoplasm. -
Answers ICD-O-3 is the system used by tumor or cancer registries for classifying the
topography and morphology of neoplasms.
The ___________ is a core component of SNOMED CT. - Answers SNOMED CT is made up of
three main components—concepts, descriptions, and relationships.
If data aggregation is the goal of collecting the data, ______ are the best choice. - Answers A
classification combines related entities. Aggregate data is appropriate when the combination of
data about related entities is sufficient.
___________ is a nursing terminology. - Answers The Clinical Care Classification is a nursing
terminology. The others are classifications.
HCPCS is made up of which code systems? - Answers HCPCS is made up of two code systems:
Level I and Level II. Level I is CPT.
Which standard is attached to the data element smoking status contained in the Common
Clinical Data Set? - Answers The data element smoking status must be reported with SNOMED
CT identifiers.
Which organization originally published ICD-10? - Answers WHO - World Health Organization
Which of the following provides the most comprehensive, controlled vocabulary for coding the
content of a patient record? - Answers SNOMED CT
, Who drives which clinical terminology, classification, and code system is selected as the
standard? - Answers Government regulation
The OASIS-C1 data elements originate from a _________. - Answers Medicare-certified home
health agency
Which of the following terms refers to the incidence of disease? - Answers Morbidity
To gather statistics for surgical services provided on an outpatient basis, which of the following
codes are needed? - Answers CPT codes
Which of the following is the condition established after study to be the reason for
hospitalization? - Answers Principal diagnosis
Which coding system has a section for Evaluation and Management services? - Answers CPT
If you were coding a patient with the diagnosis of congestive heart failure, which classification
would you use? - Answers ICD-10-CM
Which of the following classifications is used exclusively for classifying cases of malignant
disease? - Answers ICD-O-3
The first character for all of the codes assigned in ICD-10-CM is - Answers an alphabet.
The Level II (national) codes of the HCPCS coding system are maintained by the - Answers
Centers for Medicare and Medicaid Services
Which of the following is used to report the healthcare supplies, products, and services provided
to patients by healthcare professionals? - Answers HCPCS
Name two roadblocks to high quality coding. - Answers Coders who do not get correct or
updated training, and physicians who do not complete their charting on time
A list of recommended data elements with uniform definitions is a _______. - Answers Data set
The Uniform Hospital Discharge Data Set's core data elements are collected by ______. -
Answers Acute care, short-term stay hospitals
I need to confirm the patient's principal diagnosis for the chart I am coding. How should I do this?
- Answers Review documents such as nursing notes and laboratory reports
Which of the following is a standard terminology used to code medical procedures and services
and is maintained by AMA? - Answers CPT
The Unified Medical Language System (UMLS) is a project sponsored by the - Answers National
Library of Medicine.
CMS.
